U.S. OPM Form opm-opm-1644
Form Aproved:
OMB No. 3206-0240
CHILD CARE PROVIDER INFORMATION FOR THE CHILD CARE SUBSIDY
PROGRAM FOR FEDERAL EMPLOYEES
This information is required by law for the agency administrator of the Child Care Subsidy Program to verify licensure
and/or regulation status. Once you are notified by a Federal employee that they submitted an application for child care
subsidy from their Federal agency, please complete this form and return it to the parent.
Section I - Parent Information
1. Name of parent/legal guardian with child in the provider's care
2. Federal agency of parent
Section II - Provider Information
1. Type of provider (Check one)
Family Child Care
Child Care Center
Federally Sponsored Child Care Center
2. Name of child care provider
3. Address of child care provider (Include street number, city, state and ZIP code)
4. Provider e-mail address
5. Provider telephone number
6. Tax identification number or Social Security Number
7. Provider fax number
8. License number of provider
10. License expiration date (MM/DD/YYYY)
9. State in which license is issued
Section III - Child Information
Please furnish the information below for each Federal employee who applied for subsidy at your facility:
c. Does the child
receive any other
a. Name of each child in Section I b. Enrollment
subsidy?
parent's family enrolled
date
(If "Yes", complete d. Source of subsidy
(Last, first, middle initial)
(MM/DD/YYYY)
d. and e.)
Yes
Office of Personnel Management
e. Amount
of subsidy
f. Total
weekly fee
for child
No
Form authorized for local reproduction
OPM 1644
Revised May 2003
Section IV - Information on Provider's Financial Institution's Account for Payment to Provider
(Used only by Agencies that Self-Administer the Program)
1. Name of financial institution
2. Financial institution's routing number
3. Address of financial institution (Include street number, city, state, and ZIP code)
4. Type of account (For payment deposit)
(Check one)
Checking
Savings
5. Provider's account number
Section V - Signature of Provider
I understand that it is a Federal crime under United States Code 18, Section 1001, to make a false statement on this form. If I make
a false statement, I agree to be subject to criminal prosecution and punishment including a fine, imprisonment, or both.
1. Name of provider
2. Title of provider representative
3. Signature of provider (I certify that the above information is true and
correct to the best of my knowledge.)
4. Date of signature (MM/DD/YYYY)
Privacy Act Statement
Public Law 106-554, § 633 (September 29, 2000) confers regulatory authority on OPM for agency use of
appropriated funds for child care costs for lower income Federal employees. Public Law 104-134 (April 26, 1996)
requires that any person doing business with the Federal Government furnish a Social Security Number or tax
identification number. This is an amendment to title 31, Section 7701. The primary use of these Social Security
Numbers and tax identification numbers will be for identification purposes in determining eligibility for child care
subsidy. The primary use of information regarding family income (copies of pay slips and tax returns), name of
current child care provider, copies of the provider's license, statement of compliance, and information about other
child care subsidies is also used to determine eligibility for child care subsidy. Disclosure of the above information is
voluntary, but failure to provide all of the requested information may result in denial of your application.
Public Burden Statement
We think this form takes an average of 10 minutes to complete including the time for getting the needed data and
reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of
this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM),
Reports and Forms Manager, Paperwork Reduction (3206-0240), Washington, DC 20415-7900. The OMB Number,
3206-0240, is currently valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.
OPM 1644 (Back)
Revised May 2003